Download The Rip Van Winkle Effect

 The Rip Van Winkle Effect
Who Is Rip Van Winkle?
I am amazed that many young folks do not know the story of Rip Van Winkle. I
thought that this story was a part of the fabric of American culture. When I bring
up this story and get a blank look, after a sigh, I tell the story of Rip, who just
before the Revolutionary War drank some strong liquor and fell asleep under a
tree. He woke up 20 years later, only to find that much had happened and many
of his friends had been killed in the war. He eventually re-integrated into his
family and life, but not without stress and significant adjustments. Rip went back
to his old idle ways in the end.
What does this story have to do with the treatment of addiction? When people
start using drugs they tune out from their family, school, friends, and work.
Instead of dealing with a problem, they get high. If they are in their teen years,
social maturation stops. When adults start using, things change in their lives.
They lose their jobs, get divorced. Also, time passes and kids grow up. After they
“wake up” things have changed. They are real-life Rip Van Winkles.
The Problem
It is very common for us to see a 30-year-old man, who started using drugs in
high school. He often lives at home and is supported by their parents, who are
despondent with worry about what to do and also about how to protect
themselves both physically and financially from the devastation that comes with
chemical dependency and abuse. When we look closely at the maturity of our
new patient, we usually find a 14 or 15 year old in the body of a 30 year old.
While in high school we learn many of the things that we will use throughout our
lives, not only in book learning, but also on an emotional level. We learn about
disappointment and how to resolve interpersonal conflict. We learn how to control
our emotions and how to get things done, even when we want to play. If you
never deal with these issues, you do not learn these vital life skills. Another
important fact is that the brain is maturing during the later teen years. Many of
the neural connections that we need to function in the real world are formed.
Many of these people do not even have the basic skills of daily life, like writing a
check and keeping themselves and their homes clean, etc.
There is important new research that clearly shows that drug use in the early and
mid teen years leads to long-standing brain damage. Marijuana causes structural
damage seen on MRI’s and a new study released in March 2010, shows that
teens who start smoking marijuana at 14 years old have a much higher rate of
psychosis (schizophrenia and bipolar disorder) in later life as compared to those
Rip Van Winkle
Richard Gracer, MD
March 2010
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who did not start that young. If you combine these disabilities with the huge
amount of catch up that they need just to get back to square one, you have a
tremendous problem. This is all in addition to the massive damage to the brain
that is caused by drug addiction.
The Solution
How do we deal with this huge problem? The first step is to recognize that it
exists. Since there is so much for a person in recovery to learn in order to “catch
up”, we have to start with getting the brain back into a state that allows new
information to have an effect. Unfortunately, after the typical detox, the brain is
still in a “dazed” state and the patient suffers from PAWS (post acute withdrawal
syndrome). Depending upon the drug of abuse, age of the patient, length of time
of abuse, physical condition of the patient, presence of underlying mood and
other psychiatric problem (everything from bipolar disorder to anxiety), nutritional
state, and family situation, it may take quite a while to even start the process.
Unfortunately, most rehab programs end just when the ability to learn is starting
to develop.
In order to get on track as quickly as possible treatment must be aimed at all of
the areas that I have listed above. It is past the scope of this brief paper to deal
with them in depth, but a brief outline will make my point.
First, we have to realize that addiction is a brain disease and that simply stopping
use will not correct the damage to brain receptors, especially in the short and
medium term. At our clinic we use a variety of treatments that treat these altered
receptors, including buprenorphine for opiates and flumazenil for cocaine,
methamphetamine, and alcohol. We also use many other medications depending
upon each patient’s specific needs.
We also provide nutritional support aimed at replenishing the marked deficits that
develop with abuse. These treatments include the use of specific amino acids
that help the brain make more of the normal neurotransmitters, vitamins,
minerals, and even hormones when needed. We even use IV’s containing many
of these substances to help with detox and early recovery. Most treatment
centers are unaware of the vital role that these treatments play in supporting
recovery.
Next, we treat any underlying mood problems. Of these, the most common
problem that we find is anxiety. Anxiety is often the driver to “self-medicate” with
drugs of abuse and it is the most common symptom that drives relapse.
Treatment must include not only proper medication both for the receptor
problems, but also for any co morbid primary problem. (This means that the
person has both an abuse problem, as well as another independent problem
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Richard Gracer, MD
March 2010
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such as anxiety or depression.) Psychotherapy is a vital part of this process. This
can be done in a group setting, but most of these patients need individual
counseling as well.
We also have an Intensive Outpatient Program (IOP) where for three nights per
week, three hours per night for seven weeks, our patients get an intense
educational and therapeutic group experience. They also develop a peer group
that supports them in and out of the actual clinic setting. Aftercare groups provide
long term support.
We also employ transitional and sober living homes where our patients can learn
basic life and social skills. They can live in these homes for as long as it takes to
be ready to go out on their own. This may last for several months, but at times
they may stay for years.
The last point is that the treatment has to be sustained for A LONG TIME.
When a new patient comes to our clinic we outline a personalized program that
covers the first two months of treatment. This is just the start. We feel that it
takes at least a year and for many much longer to be ready for an independent
drug-free life.
After the Re-awakening
Once the patient is safely in therapy and on the road to reintegration many
families start having problems. A prime problem is the fact that while one is
addicted; they simply do not count in family decisions. By that I mean that they
check out at any indication of conflict. They take no responsibility for their actions
or for family needs. Anyone else’s needs are of no importance, only immediate
personal gratification and avoidance of cravings. The rest of the family unit learns
to live without them and suffers the blowback that they cause, be that financial,
social, or legal.
Once they start dealing with their problems, they suddenly are a part of the family
discussion. They have needs and desires. They can actually help with family
problems. For a spouse who has called the shots for so long this can be very
threatening and disruptive. The family has to learn new coping methods. It takes
a long time for trust to develop. Questions such as, “When will the next shoe
drop?” and “Can I trust that you will come through?” are very common and
understandable. It often takes intensive family therapy to straighten out these
problems.
Another aspect to consider is co-dependency. Co- dependency is defined as,
“behaviors learned by family members or significant others in order to survive in
an environment of great emotional pain and stress when a family member is
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Richard Gracer, MD
March 2010
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dependent upon the use of alcohol or drugs.” (Presbyterian Health Service). The
spouse and family learn to make excuses for the addict. They work around the
problems that they create. The pain can be intense when change occurs and it is
common for a family member to sabotage recovery. For example, in the extreme,
getting a six pack of beer if the addicted family member gets very anxious or not
allowing the addict to make a mistake or suffer the consequences of their
actions. These issues are among the most difficult to treat, but are vital.
Rip Van Winkel woke up to a very different world after his 20-year sleep. In the
end he returned to his old lazy ways. With intensive multi disciplinary treatment
we can hopefully avoid this outcome, but it takes hard work for a protracted
period of time.
To learn more about Rip Van Winkle, check out this link:
http://en.wikipedia.org/wiki/Rip_Van_Winkle
Rip Van Winkle
Richard Gracer, MD
March 2010
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